64-year-old woman evaluated before elective knee arthroplasty
A 64-year-old woman is evaluated in the preoperative clinic 5 days before scheduled elective left total knee arthroplasty. Her medical history includes hypertension and type 2 diabetes mellitus managed with lisinopril, amlodipine, and metformin. Over the past 5 weeks, she has experienced progressive exertional fatigue and dyspnea that she attributed to joint pain. She also notes waking at night with a dry cough, which she managed by elevating her head on two pillows, and bilateral ankle swelling that her surgeon suspected was an adverse effect of amlodipine. Blood pressure is 142/86 mm Hg, pulse is 86/min, respiratory rate is 18/min, and oxygen saturation is 94% on ambient air. Physical examination reveals jugular venous distension 5 cm above the sternal angle at 45 degrees, a positive abdominojugular reflux, fine end-inspiratory crackles at both lung bases, an S3 gallop audible at the cardiac apex, and symmetric 2+ pretibial pitting edema. Serum creatinine is 1.0 mg/dL, hemoglobin is 12.6 g/dL, and an electrocardiogram shows sinus rhythm with nonspecific ST-segment abnormalities. Which of the following is the most appropriate next step in management?
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D
Explanation
Clinical Pearl:
Active decompensated heart failure is an unstable cardiac condition that mandates deferral of elective noncardiac surgery. Elective procedures should be postponed until volume status and ventricular function are thoroughly evaluated and stabilized with medical therapy.
Explanation:
This patient has new-onset decompensated heart failure, evidenced by progressive exertional dyspnea, orthopnea, jugular venous distension with positive abdominojugular reflux, bibasilar rales, an S3 gallop, and peripheral edema. According to professional society guidelines on preoperative cardiovascular evaluation, active decompensated heart failure represents an unstable cardiac condition that carries an unacceptable risk of perioperative pulmonary edema and death, requiring postponement of elective noncardiac surgery until volume status and myocardial performance are optimized. Proceeding with the scheduled surgery using invasive arterial monitoring is incorrect because hemodynamic monitoring does not mitigate the substantial morbidity and mortality of operating during an active decompensation. Initiating oral metoprolol and proceeding to surgery is contraindicated, as acutely introducing or rapidly escalating beta-blockade during decompensated heart failure can depress cardiac output, and initiating beta-blockers immediately before surgery increases the risk of stroke and all-cause mortality. Performing preoperative coronary angiography is an invasive intervention reserved for acute coronary syndromes or refractory symptoms, and it is not an appropriate primary preoperative evaluation for decompensated heart failure. Preoperative pharmacologic stress myocardial perfusion imaging is used for risk stratification in patients with stable coronary disease and poor functional capacity, but it is inappropriate and potentially unsafe in the setting of uncompensated heart failure.
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